Technical implementation of percutaneous thrombus aspiration using the AngioVac system.

OBJECTIVES: The AngioVac system (AngioDynamics, Latham, NY, USA) provides a method for the minimally invasive, percutaneous aspiration of thrombus formations originating from the central venous system as well as solid matter such as lead vegetations and right atrial thrombi. METHODS: This retrospective, observational study describes the initial experience in 52 adult patients with the AngioVac system, focusing mainly on the development of the extracorporeal circuit to improve usability and safety. RESULTS: The mean patient age was 62.9 years (range 23-86 years). 22 patients were female and 30 were male. Indications for percutaneous aspiration were lead vegetations (n = 36; 69.2%), right atrial thrombi (n = 9; 17.3%), central venous thrombi (n = 5; 9.6%) and pulmonary embolisms (n = 2; 3.8%). Successful aspiration was performed in 44 cases (84.6%) and partial success was achieved in five patients (9.6%), while failure to remove thrombi or vegetations occurred in three cases (5.8%). Our practical experience led to the installation of a shunt line for recirculation and the implementation of safety features concerning air handling, which are also employed in minimally invasive extracorporeal bypass circuits. Initial tests monitored the level of negative pressure according to differences in flow and access sites but these still have to be validated on a larger scale. CONCLUSION: In this initial experience, the AngioVac system appeared to be safe regarding the extracorporeal circulation and the elimination of thrombi and lead vegetations.

Transcatheter aspiration of large pacemaker and implantable cardioverter-defibrillator lead vegetations facilitating safe transvenous lead extraction.

AIMS: Treatment of patients with systemic cardiac implantable electronic device (CIED) infection with large lead vegetations is challenging and associated with relevant morbidity and mortality. To avoid complications from open surgical extraction, a novel approach with percutaneous aspiration of large vegetations prior to transvenous lead extraction was instituted. The results of this treatment concept were retrospectively analysed in this multicentre study. METHODS AND RESULTS: One hundred and one patients [mean age 68.2 ± 13.1 (30-92) years] were treated in four centres for endovascular CIED infection with large lead vegetations. Mean lead vegetation size was 30.7 ± 13.5 mm. Two hundred and forty-seven leads were targeted for extraction (170 pacemaker leads, 77 implantable cardioverter-defibrillator leads). Mean lead implant duration was 81.7 (1-254) months. The transcatheter aspiration system with a specialized long venous drainage cannula and a funnel-shaped tip was based on a veno-venous extracorporeal circuit with an in-line filter. The aspiration of vegetations showed complete procedural success in 94.0% (n = 95), partial success in 5.0% (n = 5). Three major complications (3.0%) were encountered. Complete procedural success (per lead) of the subsequently performed transvenous lead extraction procedure was 99.2% (n = 245). Thirty-day mortality was 3.0% (n = 3). Five patients (5.0%) died in the further course on Days 51, 54, 68, 134, and 182 post-procedure (septic complications: n = 4; heart failure: n = 1). CONCLUSION: The percutaneous aspiration procedure is highly effective and is associated with a low complication profile. The aspiration of vegetations immediately prior and during the lead extraction procedure may avoid septic embolization into the pulmonary circulation. This may potentially lead to a long-term survival benefit.

Managing large lead vegetations in transvenous lead extractions using a percutaneous aspiration technique.

BACKGROUND: Treatment of patients with systemic infections of cardiac implantable electronic devices and large lead vegetations are a clinical challenge. In such situations patients potentially had to undergo open surgical extraction in the past. The objective of this study was to evaluate the results of a concomitant percutaneous, minimal-invasive aspiration procedure with the use of an extracorporeal circulation in transvenous lead extraction procedures in patients with large lead vegetations. RESEARCH DESIGN AND METHODS: Prior and during transvenous lead extraction procedures lead vegetations were targeted for removal with a percutaneous aspiration technique based on a veno-venous extracorporeal circulation with an in-line filter. Clinical outcomes of the procedures were retrospectively analyzed. RESULTS: This innovative and minimal-invasive treatment concept was used in 35 patients with systemic CIED infections (mean echocardiographic lead vegetation size 22.6 (12-40) mm). Complete procedural success of the aspiration procedure was seen in 88.6% of the patients. No major complication related to the aspiration procedure occurred. Clinical success of the concomitant transvenous lead extraction procedures (35 patients, 83 leads) was 97.1%. CONCLUSION: The presented data show that the aspiration procedure is safe and efficient as an adjunct in transvenous lead extraction procedures avoiding the need for open surgical extraction in such cases.